The modified therapeutic community (often abbreviated as “modified TC”; for consistency and the reader’s convenience, “MTC” has been used throughout this paper) was developed in the early and mid- 1990s as a treatment model and approach for those whose substance use disorders co-occurred with mental disorders. The MTC approach described in this paper was based on the theoretical framework of the standard TC model, as documented in previous publications (e.g., De Leon, 2000
), and adapted to treat individuals with co-occurring disorders (De Leon, 1993
; Sacks, De Leon, Bernhard, & Sacks, 1997
; Sacks, Sacks, & De Leon, 1999
). The core principles and methods of the TC that are especially relevant to the treatment of co-occurring disorders include: providing a highly structured daily regimen; fostering personal responsibility and self-help in managing life difficulties; using peers as role models and guides with the peer community acting as the healing agent within a strategy of “community-as-method” (the community provides both the context for and mechanism of change); regarding change as a gradual, developmental process and moving clients through progressive treatment stages; stressing work and self-reliance through the development of vocational and independent living skills; and promoting prosocial values within healthy social networks to sustain recovery.
Although most of the key elements, structure, and processes of the standard TC are maintained in the MTC model, they have been reshaped to accommodate the individual needs, impairments and deficits of clients with co-occurring disorders. The modifications have been developed to respond to the clients’ psychiatric symptoms, cognitive impairments, and level of functioning. As compared to the standard TC approach, the MTC incorporates increased flexibility, reduction in the duration of various activities, less confrontation, increased emphasis on orientation and instruction, fewer sanctions, more explicit affirmation for achievements, greater sensitivity to individual differences, and greater responsiveness to the special developmental needs of the clients, all of which serve to maximize social learning opportunities. In brief, the MTC is a comprehensive treatment model that makes three key alterations for individuals with co-occurring disorders: it is more flexible, less intense, and more individualized
. The central TC feature remains: the MTC, like all TC programs, seeks to develop a culture where clients learn through a self-help process to foster change in themselves and others, and where the community becomes the healing agent. A complete description of the MTC for clients with co-occurring disorders, including treatment manuals and guides to implementation, can be found in other writings (e.g., De Leon, 1993
; Sacks et al., 1997
The main purpose of this paper is to present a summary of four research studies undertaken over the last decade by a single investigative team examining the effectiveness of MTC treatment for clients with co-occurring substance use and mental disorders, a condition that is now commonly termed “co-occurring disorders.” Subjects in initial studies were mainly those with severe mental illness (i.e., schizophrenia and other psychotic disorders, bipolar disorders and major depression) who were, at the time, typically distinguished as having “mental illness and chemical abuse,” or MICA, disorders; for consistency in this paper, “co-occurring disorders” has been used throughout. Since the MTC was designed to address the problem of co-occurring disorders — a condition widely acknowledged to represent multiple problem areas — the paper summarizes research findings across six outcome domains (substance use, mental health, crime, HIV-risk, employment, and housing).
The paper begins with a descriptive summary of the four studies, conducted in a variety of settings and with different populations of clients with co-occurring disorders (e.g., homeless, offenders, outpatients in substance abuse treatment, and those with HIV/AIDS). Client and program characteristics of each study are noted, and the progression of the research activities is narrated, along with the alterations made to the treatment and research protocols to suit each new context. Next, the paper summarizes the findings from the four outcome studies across multiple outcome domains. The paper concludes with a discussion of the findings and proposes an agenda for future research into MTC treatment for clients who have co-occurring disorders.